Nerve monitoring and risk stratification in pediatric thyroid surgery

For Bethesda 3 thyroid nodules in pediatrics, lobectomy is recommended rather than molecular testing or repeat FNA because there is a higher rate of malignancy in those populations compared to adults

For an intermediate-risk thyroid nodule with approximately 30% cancer risk, hemithyroidectomy rather than total thyroidectomy is recommended

The 2015 pediatric guidelines recommend thyroid surgery be performed by a high volume thyroid surgeon

One recent study showed the rate of recurrent laryngeal nerve injury decreasing from 8% to 1.5% with nerve monitoring

Studies in adults have shown nerve monitoring helps identify the nerve more, but maybe doesn't change injury rates

There are no studies in pediatrics showing significant decrease in injury rates with nerve monitoring, but several show absolute decrease

The recurrent laryngeal nerve is smaller in children and may be harder to identify

The rate of recurrent laryngeal nerve injury in children is 9% versus about 6% in adults

If injury is detected on one side with nerve monitoring, waiting to see if it's transient and can recover later may be appropriate

Expense is one consideration as a downside to nerve monitoring

Some have questioned why use nerve monitoring if it doesn't change injury rates or outcomes

Recent endotracheal tube electrode publications report use in patients down to age 0

Nerve monitoring is most beneficial when doing a total thyroidectomy where the contralateral cord is at risk, to help decrease the risk of tracheotomy with bilateral paralysis

If a child is too small for standard electrodes, electrodes can be placed directly into the vocalis muscle via direct laryngoscopy for monitoring

A recent paper suggested that if size criteria are adjusted, TIRADS actually performs better than the 2015 pediatric guidelines

The PES-TIRADS (modified version) recommends biopsy for every TIRADS 3 nodule over 1 cm or TIRADS 4/5 over 0.5 cm